Efficacy of awake prone positioning in patients with covid-19 related hypoxemic respiratory failure: systematic review and meta-analysis of randomized trials

Abstract

Objective To determine the efficacy and safety of awake prone positioning versus usual care in non-intubated adults with hypoxemic respiratory failure due to covid-19. Design Systematic review with frequentist and bayesian meta-analyses. Study eligibility Randomized trials comparing awake prone positioning versus usual care in adults with covid-19 related hypoxemic respiratory failure. Information sources were Medline, Embase, and the Cochrane Central Register of Controlled Trials from inception to 4 March 2022. Data extraction and synthesis Two reviewers independently extracted data and assessed risk of bias. Random effects meta-analyses were performed for the primary and secondary outcomes. Bayesian meta-analyses were performed for endotracheal intubation and mortality outcomes. GRADE certainty of evidence was assessed for outcomes. Main outcome measures The primary outcome was endotracheal intubation. Secondary outcomes were mortality, ventilator-free days, intensive care unit (ICU) and hospital length of stay, escalation of oxygen modality, change in oxygenation and respiratory rate, and adverse events. Results 17 trials (2931 patients) met the eligibility criteria. 12 trials were at low risk of bias, three had some concerns, and two were at high risk. Awake prone positioning reduced the risk of endotracheal intubation compared with usual care (crude average 24.2% v 29.8%, relative risk 0.83, 95% confidence interval 0.73 to 0.94; high certainty). This translates to 55 fewer intubations per 1000 patients (95% confidence interval 87 to 19 fewer intubations). Awake prone positioning did not significantly affect secondary outcomes, including mortality (15.6% v 17.2%, relative risk 0.90, 0.76 to 1.07; high certainty), ventilator-free days (mean difference 0.97 days, 95% confidence interval −0.5 to 3.4; low certainty), ICU length of stay (−2.1 days, −4.5 to 0.4; low certainty), hospital length of stay (−0.09 days, −0.69 to 0.51; moderate certainty), and escalation of oxygen modality (21.4% v 23.0%, relative risk 1.04, 0.74 to 1.44; low certainty). Adverse events related to awake prone positioning were uncommon. Bayesian meta-analysis showed a high probability of benefit with awake prone positioning for endotracheal intubation (non-informative prior, mean relative risk 0.83, 95% credible interval 0.70 to 0.97; posterior probability for relative risk <0.95=96%) but lower probability for mortality (0.90, 0.73 to 1.13; <0.95=68%). Conclusions Awake prone positioning compared with usual care reduces the risk of endotracheal intubation in adults with hypoxemic respiratory failure due to covid-19 but probably has little to no effect on mortality or other outcomes. Systematic review registration PROSPERO CRD42022314856.

Comparing scientific abstracts generated by ChatGPT to original abstracts using an artificial intelligence output detector, plagiarism detector, and blinded human reviewers

“…“Efficacy of awake prone positioning in patients with covid-19 related hypoxemic respiratory failure: systematic review and meta-analysis of randomized trials” in the style of The BMJ, original article 31…”

Helmet trials: resolving the puzzle

“…Feasibility of prone positioning with helmet noninvaisve ventilation has been demonstrated [ 14 ]. A recent systematic review showed that awake prone positioning in patients with acute hypoxemic respiratory failure reduces intubation, although has no impact on mortality [ 15 ].…”

Awake prone positioning and covid-19

“…In a linked paper , Weatherald and colleagues (doi:10.1136/bmj-2022-071966) offer the most up-to-date evidence synthesis evaluating the use of awake prone positioning in adults with covid-19 related hypoxaemia,1 finding that awake prone positioning reduced the risk of endotracheal intubation but not mortality. Their systematic review and meta-analysis was performed more than 40 years after a 1976 study observed that prone positioning improved oxygenation in five patients who were mechanically ventilated for acute respiratory distress syndrome (ARDS) 2.…”

“…In clinical trials with selected populations and increased monitoring, awake prone positioning was found to be safe, with infrequent dislodgement of vascular catheters (2.5%) and skin breakdown or ulcers (0.7%) 1. Given that the definitive reductions were in endotracheal intubation and not mortality, it is worth noting that participants and clinicians could not be masked and this could bias decisions about intubation.…”